Refuah on Shabbos

When is Pikuach Nefesh overiding Shabbos?

Knowing the Halachos

1. In the Aseres HaDibros, we are commanded to keep Shabbos, but a life-threatening situation overrides Shabbos. Chazal derive (יומא פה:) based on the posuk “וחי בהם” that one should not die because of the mitzvos. Therefore, if a life is in danger, Shabbos is ignored; one may even do outright melachah to save someone.
2. Mitzvah, great person. Not only is it mutar to violate Shabbos, but it is a mitzvah, and one who is quick to act deserves praise (שו”ע או”ח שכח ס”ב). If there are talmidei chachamim present, lechatchilah they should be the ones to violate the Shabbos (רמב”ם פיה”מ, מ”ב סקל”ד) to demonstrate the halachah to the public (ט”ז סק”ה).
3. Teaching the halachos to the public. The halachos of pikuach nefesh overriding Shabbos should be taught publicly so that everyone knows in advance what to do in a situation of pikuach nefesh and no one will need to ask a shailah in real time. If the halachos were not taught, it is a disgrace to the local talmid chacham, as he is guilty of people not knowing the halachos (ירושלמי, מ”ב סק”ו). Therefore, to fulfill our obligation, we will detail here [and in the coming issue] the halachah in common situations.
4. If someone thinks there is a situation of pikuach nefesh – even if he is unsure – and because he does not know the halacha, he is afraid to violate Shabbos without asking a shailah, he is considered a murderer (שו”ע ס”א, מ”ב סק”ו).

Categories of Cholim

• Different halachos and the heter to take medicine depend on the level of illness. We will list five levels of illness [from most severe to least], the differences between them, and the relevant halachic principles. Then we will mention some halachos that depend on the level of illness.

1. Dangerously Ill Choleh [חולה שיש בו סכנה]

• If someone has an illness or pain that puts his life in danger or even presents a possible concern for his life, a Jew may violate Shabbos for him and do melachah – even deoraisa – in a normal fashion. One who is quick to act deserves praise (שו”ע שם ס”ב).

2. Danger to a Limb [סכנת אבר]

• The second level is when, due to illness or trauma, one of a person’s limbs is likely to become damaged to the point that he will be unable to use it and it will never go back to the way it was – for example, his use of the limb will be limited, or he will have a limp (ארחות שבת פ”כ אות ק”כ). This is all assuming there is no danger to the person’s life, e.g., the possibility of infection spreading or other potential complications.
• In such a case, a Jew may not do deoraisa melachah unless there is a major need, in which case he may only do it with a shinui (שש”כ פל”ג הע’ י”ח). A Jew may do derabanan melachah without a shinui and the patient may take any sort of medication. One may also tell a non-Jew to do outright melachah deoraisa for the patient (שו”ע שכ”ח סי”ז).

3. Non-Dangerously Ill Choleh [חולה שאין בו סכנה]

• The third level is when there is no danger to a person’s life, but he is ill enough that he is in bed or would be in bed if he did not force himself not to be, or his whole body is weak, e.g., due to a high fever, severe flu, or migraine. A Jew may do derabanan melachah with a shinui for such an individual (שו”ע שם סי”ז); if that is impossible, he may do it without a shinui (מ”ב ס”ק ק”ב). One may have a non-Jew do any melachah, even deoraisa.

4. Somewhat Ill [מקצת חולי]

1. Oftentimes a person is not sick in bed and his whole body is not aching, but he is weak or in pain. His situation is more than mere discomfort or a minor ache, but he continues functioning as usual. A Jew may not do any melachah for him – not even a derabanan with a shinui – and one may not have a non-Jew do deoraisa melachah for him. One may have a non-Jew do derabanan melachah for him since that is a double derabanan in a case of moderate illness (שו”ע סי’ ש”ז ס”ה). One may not take medication for this level of illness unless he does so in a permissible way [discussed below (23 and on)].

5. Minor Ache [מיחוש]

1. The lowest level is when a person is only experiencing minor discomfort, e.g., due to a mild cold or ache, and there is no concern that his situation will deteriorate. Chazal did not permit any issurim in these circumstances, not even derabanan issurim through a non-Jew (שו”ע סי’ שכ”ח ס”א, מ”ב סק”ג וסקפ”ג). Also, one may not take medicine to heal or relieve this type of ache.
2. Determining the level of illness. In truth, it is difficult to set forth the levels of illness in writing. Everyone reacts differently to different sensations and pains. One should know that if he has any doubt about treating an illness, he can be meikel and place it on the more serious level. Certainly with respect to medication, one can classify it as the more serious illness (שו”ת משנת יוסף ח”ו סי’ צ”א).

Taking Medicine on Shabbos

1. It is not simply mutar to take medicine on Shabbos in any way for any level of illness. Thus, it is necessary to know the rules of when one may take medicine on Shabbos and when it is assur. Though it is impossible to list every case here, we will try to lay out some general principles. In every case, one should consult a doctor and then a rav with expertise in the area.

Gezeirah of Grinding Ingredients for Medicine

1. Chazal decreed that a person not perform actions to heal a choleh on Shabbos. They were concerned it would lead to preparing a cure by grinding ingredients, thereby violating the melachah of tochein. Even if a particular remedy does not involve forbidden melachah on Shabbos, Chazal forbade the actions of healing themselves.
2. Massage. Therefore, if someone’s muscles are a bit sore, he may not massage the area to relieve the soreness. This is because medicine can also relieve soreness, so there is a concern he might grind ingredients to bring relief. However, one may do something to alleviate pains that cannot be treated with medicine – in such a case, there is no concern of grinding ingredients (שו”ע סי’ שכ”ח סמ”ג).
3. Taking medicine. Therefore, one may not take medicine on Shabbos even if it was prepared before Shabbos since Chazal forbade the actions of healing themselves on Shabbos.

Which Level of Illness?

1. May take any medicine. Cholim on levels 1, 2, or 3 – dangerously ill, danger to a limb, and a non-dangerously ill choleh whose whole body is weak or who stops functioning properly – may eat, drink, or swallow any type of medicine intended to help them or heal their illness. They may take medicine because Chazal never intended to apply the decree to cholim like these (רמ”א סי’ שכ”ח סל”ז, מ”ב ס”ק קכ”א, שו”ת שבט הלוי ח”ח סי’ פ”ב, חוט שני ח”ד פפ”ט סקכ”ו).
2. Chronic illness. Obviously, someone who takes medicine regularly for a chronic illness, e.g., a heart condition, high blood pressure, diabetes, or the like, must take his medicine as usual on Shabbos too, as his illness is categorized as one that affects the whole body.
3. May not take medicine. A person who is only somewhat ill (level 4) or has a minor ache (level 5) may not take medicine on Shabbos because of the gezeirah against grinding ingredients for medicine (above, 14), except under certain circumstances that will be discussed below.

Children, Elderly, Weak

• Children. A child’s needs are considered needs of a non-dangerously ill choleh (רמ”א סי’ שכ”ח סי”ז). Therefore, children may take any type of medicine to alleviate any slight ache or pain. Some say this is until the age of six or seven (יעב”ץ מגדל עוז, דעת תורה הובא בשו”ת מגדנות אליהו סוף ח”ד הע’ לסי’ שכ”ח); others say this goes all the way until nine (שו”ת מנחת יצחק ח”א סי’ ע”ח, ח”ט סי’ ל”ה).
• Elderly. If an old person is totally healthy and does not suffer from anything, he does not have the status of a choleh. However, elderly people usually are somewhat weak, have lower immunity, and are susceptible to serious illness. Thus, they may take medicine as required.
• Weak. Someone who is weak or immunocompromised can take any type of medicine, whether it is something he takes regularly or not, even for a minor ache so that he does not become more ill and ח”ו get to the level of illness in the entire body (פסקי תשובות שכ”ח אות לח).

When Is It Permissible to Take Medicine?

• Although someone who is not classified as a true choleh may not take medicine on Shabbos, there are many cases and considerations to permit it. Therefore, before one is machmir for himself or others not to take medicine on Shabbos, he should check if he is allowed to, as the ailment can detract from his enjoyment of Shabbos.
• Modern medication. Some say that there was only a concern that taking medicine might lead to grinding ingredients back when people made medicine at home. No one makes medicine at home today; every step of the process is done in a pharmaceutical manufacturing plant. Even in pharmacies, medicines are basically never made by grinding raw ingredients. Thus, one can be meikel to take medicine (שו”ת רבי עקיבא יוסף ח”א סי’ קכ”ב) since even Chazal were meikel in certain cases where the concern of grinding ingredients did not exist, e.g., when the medicine was mixed into food before Shabbos (below, 27). At the very least, this reasoning can be used to be meikel in a case where it is unclear if one is considered a choleh or if there is a machlokes on the matter (קצות השלחן סי’ קל”ד ס”ד עמ’ י”ט כ’ בבדה”ש).
• Medicine taken for a number of consecutive days. If the doctor tells someone to take a medicine for a certain number of consecutive days, and if he skips a day, the medicine will not be fully effective [e.g., someone with pain in his ear or eye that does not present a risk of developing into a true illness], multiple poskim say he may take the medicine on Shabbos too (הגר”ש קלוגר, ספר החיים סי’ שכ”ח, דינים והנהגות מהחזו”א פט”ו ס”א). Some allow this even if the course of the medication is only five days, for example. Some even allow starting on erev Shabbos (בעל קהילות יעקב).
• Preventive medication. If a person is not considered a choleh, i.e., he does not belong in bed and is not ill in his whole body, but he feels that if he does not take medication, he will become sick and have to go to bed, even if that will only happen after Shabbos, he may take medicine now to prevent illness even if the illness presents no danger whatsoever (אג”מ או”ח ח”ג סי’ נ”ג, הגרשז”א, שש”כ פל”ד הע’ ע”ו).

Mixing into Food or Drink

• If one needs to take medicine on Shabbos but he is not considered sick in his whole body and does not belong in bed, he can mix the medicine into food or drink so it is not obvious he is taking medicine and then take it on Shabbos. Lechatchilah, he should try hard to mix it into the food or drink before Shabbos (ע”פ השו”ע סי’ שכ”ח סכ”א, קצות השלחן סי’ קל”ח הע’ ל”א, שו”ת מנח”י ח”ו סי’ כ”ח, שו”ת באר משה ח”ד סי’ ל”א).

Medicine for a Healthy Person

• Completely healthy people without any pains sometimes need to take certain medications, e.g., sleeping pills for sleeplessness not due to illness, or pills especially meant for men or women. Since they are only taken to maintain proper body function rather than cure anything (שו”ת באר משה ח”א סי’ ל”ג), the poskim allow taking them on Shabbos (שו”ת חלקת יעקב או”ח ח”א סי’ ק”נ).

Medicine for Different Ailments

• Headache, migraine. If a person has a small headache and he knows that if he doesn’t take a certain medicine, it will develop into a severe headache, e.g., a migraine, he may take the medicine right away to prevent the development of the ailment (ארחות שבת פ”כ אות קכ”ה).
• Allergies, hay fever. Seasonal allergies depend on the person. Some people suffer very much and do not function properly even though they are not bedridden. Such a person is considered ill throughout his body (מו”ר בעל שבט הקהתי) and may take medicine (above, 17). Also, people usually take allergy medications in the beginning of the morning or evening, before the onset of symptoms, which can also be permitted as preventive medication (26). If someone experiences minor discomfort from allergies but does not really suffer, it is best to mix the pill into food before Shabbos (שו”ת באר משה ח”ד סי’ ל”א).
• Heartburn. People often suffer from heartburn on Shabbos, especially after eating a lot at the seudah and going straight to sleep. If one just feels minor irritation but is not suffering much, he may not take tablets such as Tums™ on Shabbos. However, if he suffers so much that he is not functioning normally, he may take them.
• If one has a stomach ulcer or chronic acid reflux and takes a pill such as omeprazole or lansoprazole before eating to prevent intense pain afterward, he can do so on Shabbos as a preventive medication (26).
• Mental health. If one takes medication for a mental health condition, e.g., depression, anxiety, psychosis, etc., he can take the medication on Shabbos since oftentimes such a person does not function properly without it. Also, sometimes it is dangerous for a person not to take his medicine (מו”ר בעל שבט הקהתי).
• Attention, concentration. One may also take medications for attention or concentration, e.g., Ritalin or Adderall, because they do not cure illness; they just maintain proper functioning (28).
• Flu, cold. If someone has a small cold but is not bedridden or weak throughout his body, he should not take medicine unless he does so under the permissible circumstances mentioned above. However, if one is suffering a lot from a cold or has severe symptoms of the flu [currently known as “omicron”…], he may take medicine to treat it since he is considered “sick in his whole body.”
• Nasal congestion. If one has a stuffed nose, he may not use nasal drops for relief (שו”ת מנחת יצחק ח”ח סי’ ה’). However, he may smell intense aromas, e.g., snuff or Vicks, to open his nasal passageways and make breathing easier, as these things do not actually provide healing (שו”ת באר משה ח”א סי’ ל”ג אות י”ב).